WARNING! THIS LEGAL DOCUMENT REFLECTS THAT A CONSTRUCTION LIEN HAS BEEN PLACED ON THE REAL PROPERTY LISTED HEREIN. UNLESS THE OWNER OF SUCH PROPERTY TAKES ACTION TO SHORTEN THE TIME PERIOD, THIS LIEN MAY REMAIN VALID FOR ONE YEAR FROM THE DATE OF RECORDING, AND SHALL EXPIRE AND BECOME NULL AND VOID THEREAFTER UNLESS LEGAL PROCEEDINGS HAVE BEEN COMMENCED TO FORECLOSRE OR TO DISCHARGE THIS LIEN. CLAIM OF LIEN STATE OF ____________________ COUNTY OF ____________________ Before me, the undersigned notary public, personally appeared ______________________________, who was duly sworn and says that he/she is the lienor/agent of the lienor, whose address is ________________________________________; and that in accordance with a contract with ______________________________, lienor furnished labor, services, or materials consisting of ___________________________________ on the following real property described in Brevard County, Florida: owned by ______________________________ of a total value of $__________, of which their remains unpaid $__________, and furnished the first of the items on ____________________, 20___, and the last of the items on ____________________, 20___; and (if the lien is claimed by one not in privity with the owner) that the lienor served his/her notice to owner on ____________________, 20___, by _________________________; and (if required) that the lienors served copies of the notice on the contractor on ____________________, 20___, by _________________________ and on the subcontractor, ______________________________, on ____________________, 20___, by _________________________. ____________________________________ Signature ____________________________________ Name of Lienor/Agent SWORN TO AND SUBSCRIBED before me this _____ day of ____________________, 20___, by ______________________________, who is personally known or produced ______________________________ as identification. ____________________________________ Signature of Notary ____________________________________ Name of Notary Public American LegalNet, Inc. www.FormsWorkFlow.com